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PapersSizeatbirthandresiliencetoeffectsofpoorlivingconditionsinadultlife:longitudinalstudyDJPBarker,TForsén,AUutela,COsmond,JGErikssonAbstractObjectiveTodeterminewhethermenwhogrewslowlyinuteroorduringinfancyaremorevulnerabletothelatereffectsofpoorlivingconditionsoncoronaryheartdisease.
DesignFollowupstudyofmenforwhomthereweredataonbodysizeatbirthandgrowthandsocialclassduringchildhood,educationallevel,andsocialclassandincomeinadultlife.
SettingHelsinki,Finland.
Participants3676menwhowerebornduring1934-44,attendedchildwelfareclinicsinHelsinki,werestillresidentinFinlandin1971,andforwhomdatafromthe1980censuswereavailable.
MainoutcomemeasuresHospitaladmissionforordeathfromcoronaryheartdisease.
ResultsMenwhohadlowsocialclassorlowhouseholdincomeinadultlifehadincreasedratesofcoronaryheartdisease.
Thehazardratioamongmenwiththelowestannualincome(140(15700)45/7341.
000.
002111-140(15700)61/7761.
34(0.
91to1.
96)96-110(12400)41/5951.
26(0.
82to1.
92)75-95(10700)64/7471.
52(1.
03to2.
22)118(13300)1.
001.
74(1.
03to2.
94)2.
05(1.
20to3.
50)87-118(13300)0.
92(0.
39to2.
14)1.
79(1.
07to2.
99)1.
63(0.
97to2.
74)26.
0(n=2154)Hazardratio(95%CI)Unadjusted(adjusted)PvaluefortrendHazardratio(95%CI)Unadjusted(adjusted)PvaluefortrendInfancyFather'ssocialclass:Uppermiddle1.
000.
06(0.
41*)0.
76(0.
32to1.
84)0.
006(0.
02*)Lowermiddle1.
52(0.
71to3.
27)1.
05(0.
49to2.
27)Labourer1.
86(0.
94to3.
68)1.
60(0.
81to3.
16)EducationLevelofeducation:High1.
000.
0040.
60(0.
30to1.
20)0.
007Middle1.
29(0.
73to2.
27)1.
50(0.
88to2.
55)Low2.
00(1.
17to3.
42)1.
47(0.
86to2.
51)Adultlife(1980)Socialclass:Higherofficial1.
00140(15700)1.
00<0.
0001(0.
0001)1.
19(0.
65to2.
19)0.
75(0.
84)111-140(15700)1.
54(0.
83to2.
87)1.
42(0.
78to2.
57)96-110(12400)1.
07(0.
51to2.
22)1.
66(0.
90to3.
07)76-95(10700)2.
07(1.
13to3.
79)1.
44(0.
79to2.
62)<75(8400)2.
58(1.
45to4.
60)1.
37(0.
75to2.
51)*Adjustedforadultsocialclass.
Adjustedforfather'ssocialclass.
Table4Hazardratiosforcoronaryheartdiseaseinmenwithponderalindexatbirth<26kg/m3,accordingtoadultsocialclassandchangesinbodymassindex(BMI)betweenages1and12yearsSocialclassChangeinSDscoreforBMIDecrease*IncreaseHigherofficial1.
38(0.
55to3.
52)1.
00Lowerofficial1.
14(0.
38to3.
40)1.
84(0.
70to4.
85)Selfemployed0.
69(0.
09to5.
62)2.
93(0.
86to10.
01)Labourer2.
18(0.
88to5.
39)3.
78(1.
68to8.
53)*P=0.
24fortrend.
P<0.
0001fortrend.
Papers3BMJVOLUME3231DECEMBER2001bmj.
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DownloadedfromInfantgrowthandsocialclassAshaspreviouslybeenshown,wefoundthathavingafatherwithlowsocialclassincreasedtheriskofcoron-aryheartdiseaseindependentlyofaman'sownsocialclass.
10–13Growthduringinfancywasreducedinfamiliesoflowsocialclass,andpoorinfantgrowthisassociatedwithincreasedriskofdisease,possiblythroughalteredlivergrowthandconsequentre-programmingoflipidmetabolismandbloodcoagulation.
1415Theeffectsoflowsocialclassoncoronaryheartdisease,however,wereonlypartlyexplainedbytheireffectoninfantgrowth.
Itsothereffectscouldbelinkedtoitsstrongassociationwithpooreducationalattainment.
EducationWefoundthatpooreducationalattainmentwasassoci-atedwithlatercoronaryheartdisease.
Menwhoachievedonlylowlevelsofeducationhadreducedinfantgrowth,butthisexplainedonlyasmallpartoftheassociation.
OnepossibleexplanationhasbeensuggestedbyafollowupstudyofchildrenborninAberdeen,Scotland.
16Thosewhohadlowerscoresinamentalabilitytestat12yearsofagediedyounger.
WhalleyandDrearyproposedthatperformanceinintelligencetestsmightreflectgeneralaspectsofchild-hoodfitnessrelatedtolongtermhealth.
Greaterintel-ligenceandhigherlevelsofeducationcouldalsobeassociatedwithhealthierbehaviourinadultlife.
LivingstandardsinadultlifeAsexpected,lowsocialclassandlowincomewereassociatedwithincreasedratesofcoronaryheartdisease.
71718Wefound,however,thattheseeffectswerestrongerinmenwhowerethinatbirth,especiallyiftheyhadhadacceleratedweightgaininchildhood.
Taxablehouseholdincomewasstronglyrelatedtoeducationalattainment.
Wefoundthatbetteredu-cationalattainmentprotectedmenfromtheharmfuleffectsoflowincome.
Thewayinwhichlowincomemayincreasecardiovascularriskiscontroversial.
Lynchetalhaveemphasisedthematerialconsequencesoflowincomeonlivingconditions.
19Whilebettereduca-tionmayenablepeopletoreducetheeffectsoflowincomeontheirlivingstandards,itissurprisingthatwefoundnoeffectofincomeonceeducationwastakenintoaccount.
MarmotandWilkinsonhaveemphasisedthepsychosocialconsequencesofalowpositioninthesocialhierarchy,asindicatedbylowincome,andsuggestedthatperceptionsoflowsocialstatusandlackofsuccessleadtochangesinneuroendocrinepathwaysandhencetodisease.
20Ourfindingsseemconsistentwiththishypothesis,althoughtheypointtotheimportanceofahierarchydefinedbyeducationratherthanincome.
Thehypothesiscouldalsoexplainwhy,inourstudy,lowincomewasassociatedwithcoronaryheartdiseaseonlyinavulnerablegroupdefinedbylowratesofintrauterinegrowth.
Peoplewhoaresmallatbirthareknowntohavepersistingalterationsinresponsestostress,includingraisedserumcortisolconcentrations.
21Rapidchildhoodweightgainmayexacerbatetheadverseeffectsofsmallsizeatbirth.
22ConclusionOurresultsshowthatstudiesofthedevelopmentalori-ginsofcoronaryheartdiseasemayrevealnewbiologi-calpathwaysthroughwhichsocialinfluencesaffecttheriskofdisease.
23Peoplewhoserateofgrowthinfetallife,infancy,andchildhooddiffersfromthenormremainbiologicallydifferentandareatincreasedriskofcoronaryheartdisease.
Socialinfluencesthataltergrowthmaythereforealtertheriskofdisease.
Conversely,alteredearlygrowthmayincreasevulner-abilitytotheeffectsofpoorlivingstandardsinadultlife.
Therefore,improvementsinfetal,infant,andchildgrowthmaypreventcoronaryheartdiseaseinthenextgenerationbyimprovingthebody'sfitnessandmakingitresilienttolatersocialadversity.
WethankTerttuNopanen,TiinaSaarinen,Hillevifverstrm-Anttila,ArjaPurtonen,TiinaValle,HannaPehkonen,andUllaTarvainenforabstractingthedatafromtherecords.
SigridRos-tenwasresponsiblefordatamanagement.
LiisaToivanencoor-dinateddataabstraction.
Contributors:Alltheauthorstookpartinthedesignandanalysisofthestudyandjointlywrotethepaper.
ThedataabstractionandlinkageweresupervisedbyJGEandTF.
JGE,CO,andDJPBwillactasguarantorsforthepaper.
Funding:BritishHeartFoundation,JahnssonFoundation,FinskaLkaresllskapet,NovoFoundation.
Competinginterests:Nonedeclared.
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WhatisalreadyknownonthistopicPeoplewhogrowslowlyinuteroandduringinfancyremainbiologicallydifferentthroughtheirlivesSuchpeopleareatincreasedriskofcoronaryheartdiseaseWhatthisstudyaddsAmongmenwhowerethinatbirththeriskofcoronaryheartdiseaseisfurtherincreasediftheyhavepoorlivingstandardsinadultlifeOthermentendtoberesilienttotheadverseeffectsofpoorlivingstandardsPapers4BMJVOLUME3231DECEMBER2001bmj.
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(Accepted29August2001)Papers5BMJVOLUME3231DECEMBER2001bmj.
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